Factors Influencing the Life Expectancy of Aboriginal and Torres Strait Islander People

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The World Health Organization (WHO) defines health inequality as the “differences in health status or in the distribution of health determinants between different population groups” (WHO, 2017, para. 2). When looking at Australia’s health inequities it is evident that Aboriginal and Torres Strait Islander People experience significantly lower life expectancy than Non-Indigenous people. More specifically recent statistics indicate that the life expectancy of Indigenous Australians is 10 years lower than that of non-Indigenous Australians (Australian Institute of Health and Welfare, 2016). This essay aims to explore the possible biological and psychosocial factors that contribute to this inequity and therefore analyse the possible solutions to reduce the disparities between the population. Furthermore, this essay aims to add to literature on Ingenious Australian health and to gain a more in depth understanding of health inequities by a particular group of people.

To begin this essay, it is important to explore the health status of Aboriginal and Torres Strait Islander in Australia compared to that of non-Indigenous Australian’s. Aboriginal and Torres Strait Islander people experience significantly more ill health than other Australians. Across a wide range of determinates of health, the indigenous population is disadvantaged. Infant morality rates are almost two times higher than the rest of the population. (Australian Institute of Health and Welfare, 2015). They experience higher rates of unemployment, lower incomes, lower education levels, poorer housing and lower levels of home ownership. (Australian Institute of Health and Welfare, 2015). All these factors can be seen to have a relationship between the lower life expectancy experienced by this population. More specifically, literature on biological, behavioural, social and physical environmental factors will be investigated to determine why these statistics are evident.

Biological determinants of health are factors that relate to the body which impact on health. (Brown, Carrington, McGrady., Lee, Zeitz,, Krum and Stewart, 2014). For example, Obesity is a biological factor that is prevalent among indigenous Australians and can contribute to lower life expectancy. “It has been reported that Indigenous Australian men are 1.6 times more likely to be obese than non-Indigenous men and that Indigenous women are 2.2 times more likely to be obsess than their non-Indigenous counterparts”. Birch (2015) discusses the links between obesity and health problems and concluded that “individuals who are obese are more at risk of suffering from heart disease, diabetes and some forms of cancers”. This is especially the case for Indigenous Australians whereby nearly 50 percent of the population who are obese suffer from diabetes and over 43 percent suffer from heart and circulatory diseases (Australian Bureau of Statistics 2008) “There have been many medical studies that have examined the factors associated with obesity.

A key finding from this literature is that obesity is a result of genetic factors and heritability are the main determinants of an individual’s susceptibility to obesity, accounting for 80 percent of the prevalence of obesity.(Swarbrick, 2002; Wardle, Carnell, Haworth, and Plomin, 2008). “Most medical studies, however, fail to explain why the prevalence of obesity has increased so dramatically in recent years, given that genetic factors tend to change slowly over time” (Chou, Grossman and Saffer, 2004). “In an aim to reduce the percentage of Aboriginal and Torres Strait Islander people suffering from obesity, “The Council of Australian Governments has highlighted the need to address poor Indigenous health through the Closing the Gap in Indigenous Disadvantage initiative and has set a target aim to close the gap in life expectancy by 2031”. “In 2010–2012, the gap in life expectancy was 10.6 years for men and 9.5 for women” (Holland, 2014). “The increased likelihood of suffering from various health conditions caused by obesity has been reported to lower life expectancy by up to 8 years for men and 6 years for women” (Grover, Kaouache, Rempel, Joseph, Dawes, Lau,and Lowensteyn, 2015). “Hence, reducing the higher rate of obesity for Indigenous Australians is paramount to closing the gap in life expectancy between Indigenous Australians and the rest of the Australian population.”

Behavioural determinants of health are defined as people’s choices that influence on their health and thus related to their lifestyle

.

(Laws, Grayson, and Sullivan, 2006). One of the major behavioural determinates that lowers the life expectancy of Aboriginal and Torres Strait Islander people is that of tobacco smoking. “When compared to the overall Australian population, Aboriginal and Torres Strait Islander peoples have a substantially higher prevalence of smoking for all age groups among both men and women.” (The Cancer Council Australia, 2019). “Thirty-nine per cent of the combined Aboriginal and Torres Strait Islander population aged 15 and over were daily smokerscompared with 14% in the general population.”(Van der Sterren, Greenhalgh, Knoche, and Winstanley 2018) “After adjusting for differences in age structure, Aboriginal and Torres Strait Islander peoples aged 15 years and over were almost three times as likely as non-Indigenous people to be daily smokers.” (The Cancer Council Australia, 2019). “Prevalence appeared to be slightly higher among Aboriginal peoples” (39%) “than Torres Strait Islander people” (35%) (The Cancer Council Australia, 2019). “More importantly a study with pregnancy Australian indigenous women reported smoking prevalence rates between 50% and 67%, approximately three time that in non-indigenous population.” (Passey, D’Este and Sanson-Fisher, 2012) “Smoking during pregnancy is associated with increased risk of maternal and infant adverse outcomes.” (Laws, Grayson, and Sullivan, 2006). “”For the mother, these include higher rates of placental abruption, placenta praevia, premature labour and premature rupture of membranes” (Laws Grayson and Sullivan, 2006). “For the baby, adverse outcomes include low birth weight, preterm birth, intrauterine growth retardation, perinatal death and Sudden Infant Death Syndrome” (Laws, Grayson, and Sullivan, 2006). Examination of population-level data confirms these adverse outcomes among Aboriginal women. (Chan A, Keane RJ, Robinson, 2001) A study conducted by Passey, D’Este and Sanson-Fisher (2012) found that lower levels of education and socio-economic status was associated with higher rates of women smoking during pregnancy and therefore smoking cessation knowledge was essential in Aboriginal and Torres Strait Islander communities. Since conducting smoking cessation knowledge and educating the Indigenous community on the effects of tobacco smoking “there have been progressive decreases in smoking prevalence among Indigenous Australians over time. The prevalence of current (i.e., daily and less often) smoking among Indigenous adults declined by 2.4% between 1994 and 2004, from 54.5% to 52.1%.”(The Cancer Council Australia, 2019). There were also declines in more recent years, from 49.8% in 2008, to 44.5% in 2015. %”.”(The Cancer Council Australia, 2019) “Since 2000 the Townsville Aboriginal and Islander Health Service’s Mums and Babies Project increased the numbers of women presenting for antenatal care”(from 40 to over 500 visits per month in 1 year). “The number of antenatal visits made by each woman has doubled, with the number having less than four visits falling from 65% to 25%. Pre-natal deaths per 1,000 reduced from 56.8 prior to the program to 18 in 2000”; “the number of babies with birth weights less than 2,500 grams has dropped significantly; and the number of premature births has also decreased” (Australian Human Rights Commission, 2019)

Social determinants refer to aspects of society and the social environment that influence on health. They generally relate to contact with other people in someone’s community. (Marmot ,2011) One social determinant that can be seen to have a relationship with lower life expectancy among indigenous Australians is that of lower levels of education. (Marmot ,2011). “There is a correlation between lower levels of education among Aboriginal and Torres Strait Islander people and engaging in risky behaviours such as unprotect sex which can lead to sexually transmitted diseases.” (Wand, Bryant, Worth, Pitts,Kaldor, Delaney-Thiele, and Ward, 2017). “Aboriginal people make up 3% of the Australian population; however, in 2014, they accounted for 34% and 21% of all gonorrhoea and chlamydia notifications respectively.” (Wand, Ward, Bryant, Delaney-Thiele ,Worth, Pitts, Kaldor, 2016) “Further, socioeconomic conditions, such as inadequate access to health care, low levels of STI testing within mainstream primary health care settings, high community prevalence and high mobility between communities, also make Aboriginal young people particularly vulnerable to STIs.” (Wand, et. Al, 2017) “Overall the prevalence of regular alcohol intake per week was higher in the indigenous community than non-indigenous community” (49% in males and 37% in females) “can be seen to have a relationship between the number of sexual encounters experienced within the community”. (Wand, et. al, 2016)

“One of the most robust results from the present study is the strong association between early onset sexual activity and subsequent risky sexual behaviours that have been established to be associated with STIs, The results showed that young Indigenous men and women who initiated sexual activity at earlier ages were significantly more likely to engage in risky sexual behaviours. Historically, Aboriginal and Torres Strait Islander peoples have not had the same opportunity to be as healthy as non-Indigenous people. This occurs through the inaccessibility of mainstream services and lower access to health services, including primary health care, and inadequate provision of health infrastructure in some Aboriginal and Torres Strait Islander communities.”((Australian Rights Commission, 2019) “The Northern Territory Well Women’s Program, which operates in a region with a high proportion of Aboriginal women and has a long history of engagement with women and local Aboriginal Health Services, has achieved a high rate of cervix screening (61%) in the Alice Springs remote area, which is comparable to the rate for Australian women generally” (62%).

Lastly, Physical environment determinants refer to the impact of the physical surrounding in which we live, work and play on our health. (Healey, 2008). “Indigenous peoples do not have an equal opportunity to be as healthy as non-Indigenous Australians. The relative socioeconomic disadvantage experienced by Aboriginal and Torres Strait Islander people compared to non-Indigenous people places them at greater risk of exposure to behavioural and environmental health risk factors

”. (Australian Human Rights Commission, 2019) as does the higher proportion of Indigenous households that “live in conditions that do not support good health”. (Booth and Carroll, 2005). In 2006, 31% of houses in Indigenous communitie required major repair and replacement. (Booth and Carroll, 2005). These posed health risks including risk of injury or disease “Indigenous peoples also do not enjoy equal access to primary health care and health infrastructure” (including safe drinking water, effective sewerage systems, rubbish collection services and healthy housing) (Healey, 2008). These physical environments have been seen to have an impact on mental health and therefore has been seen to have a relationship with lower life expectancy in Indigenous communities. (Healey, 2008). “High rates of mental health problems also indicate chronic stress in a population group.” (Australian Human Rights Commission, 2019) “In 2003-04, Indigenous people were up to twice as likely to be hospitalised for mental and behavioural disorders as other Australians.” (Australian Human Rights Commission, 2019) A mental health project was introduced at the Geraldton Regional Aboriginal Medical Service reduced psychiatric admissions of Aboriginal and Torres Strait Islander people to Geraldton Regional Hospital by 58%. (Australian Human Rights Commission, 2019)

In Conclusion, this essay explored the health inequities between Aboriginal and Torres strait Islander people to the rest of Australians. It was discussed that life expectancy was significantly lower in Indigenous people due to various biological, behavioural social and physical environment determinants. Therefore, this essay explored the ways in which life expectancy can be increased by referring to existing literature and through suggestions for the future.


References

use of force policy and the necessity of law

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Society’s failure to understand law enforcement’s use of force policy and the necessity of law causes an excessive negative interpretation of police instead of a war on crime.

Society’s failure to understand law enforcement’s use of force policy and the necessity of law causes an excessive negative interpretation of police instead of a war on crime.

Policy Analysis: Temporary Assistance for Needy Families (TANF)

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Policy Analysis: Temporary Assistance for Needy Families (TANF)


Abstract

The goal of this paper is to perform a policy analysis of the 1996 Temporary Assistance for Needy Families (TANF) under the Personal Responsibility and Employment Opportunity Reconciliation Act (PRWORA) and its impact on families with children. TANF is the main safety net and cash assistance program available to provide aid for children in poverty. For perhaps the first occasion since it was created the 1935 Social Security Act, the implementation of TANF has assumed a fundamental shift in federal welfare policy (Fusaro 2019). The policy plan for eliminating child poverty by relying on jobs and marriage has failed to help households gain financial self-sufficiency and upward economic prosperity. The paper would concentrate on the history of TANF and how kids living in poverty have been affected It will also examine the efficacy of TANF in reaching its stated policy goals.


Introduction

There is a substantial number of people living in poverty in the United States. In accordance with U.S. data, The Census Bureau (2011) estimates that 15.7 million children live on or below the poverty line, representing 21.6% of all children. Poverty can impact many aspects of a child’s life, including access to proper needs and resources, safety, health, and adult quality of life (Duncan, Ziol-Guest, & Kalil 2010). Not only does it affect an individual during their childhood when facing poverty at a vulnerable age, but it can also lead to adverse consequences for those children as they move through life. Childhood poverty impacts some groups and family units disproportionately. Black and Hispanic children have considerably greater rates of poverty than the national average, with 38.2% of Black children and 32.3% of Hispanic children living in poverty (U.S. Census Bureau, 2011). It is far above the national average of 21.6% all children and more than double the more level for white children, 17.0% of whom live in poverty (U.S. Census Bureau, 2011). TANF’s policy analysis will include an in-depth understanding of the program’s results for vulnerable children and families.

Childhood poverty in the United States is a major and severe problem. Temporary Assistance for Needy Families (TANF) is the current federal welfare policy in place to deal with this problem. TANF was established as Title 1 of the Personal Responsibility and the work Opportunity Reconciliation Act of 1996 (PRWORA). TANF was established as a response to the growing number of children living in poverty and needing government assistance under the preceding welfare system. TANF has been and appears to be one of the main security net and cash assistance programs available in the country to support low-income families with young children. In 1996, TANF replaced the federal welfare aid formerly provided under Aid to Families with Dependent Children (AFDC) and related programs with the TANF block grant (Lawrence 2013). AFDC was an uncapped federal incentive system whereby states earned more federal money when they allocated more on cash assistance and less when they caseloads decreased (Lawrence 2013). In comparison, TANF jurisdictions were granted a specified block grant from which they can spend on a broad variety of programs to forward either of the four federal objectives.

TANF also has a provision for “maintenance of energy” (MOE) that states will continue to spend at least 75% of the total they invested on services supporting needy families previous to the welfare reform. States will spend money on a variety of programs and facilities to poor families with children, independent of whether households seek financial assistance. TANF was designed to minimize the number of children in need of government benefits as well as to receive them. The objectives of TANF were too:

(1)Provide assistance to needy families so that children may be cared for in their own homes or in the homes of relatives; (2) end the dependence of needy parents on government(“TANF State Plan”) benefit by promoting job preparation, work, and marriage; (3) prevent and reduce the incidence of out-of-wedlock pregnancies and establish annual numerical goals for preventing and reducing the instance of these pregnancies’(Dobelstein, 2009) and (4) encourage the formation and maintenance of two-parent families. (PRWORA, 1996, Sec. 401).


Background

Block grants have been given to states to create their own programs. The sum of the award is based on the number of people in each state who had previously received assistance from AFDC. It was anticipated that the amount of revenue would be reduced by 10 percent each year with the attempt to gradually wean off people on welfare (PRWORA, 1996).

TANF’s establishment has significantly changed U.S. welfare policy. Welfare was no longer an entitlement program like it was under AFDC, offering support to everyone who eligible as long as they qualified. TANF is time-limited; families in their entire life only can receive welfare for a maximum of 60 months, and states have the choice of further minimizing that time-limit. States were also offered the option of imposing a limit on the number of children qualified for assistance per household. Through TANF, people are required for a minimum number of hours per week to operate or engage in job-related activities in order to stay eligible for the service. Throughout 1997, people on welfare were originally contracted to work 20 hours a week, rising to 30 hours by 2000. States must fulfill their work quotas with a certain percentage of their recipients or face large fines and funding cuts (PRWORD, 1996).

The 2005 Deficit Reduction Act (DRA) re-authorized TANF. The DRA expanded the types of families required to achieve the work quotas, such as previously exempt families, such as parents who do not receive cash aid on their own, only for their children (Reed & Karpilow, 2010). This doubled the number of total TANF participant states to be included when determining their percentages of families meeting the work requirements (Reed & Karp, 2010).


The critique

The policy’s overall value principle is that kids should not live in poverty. The clear quality principles driving the policy goals are the relevance of infant well-being for education and marriage (PRWORA, 1996). In 1994, only 7.9% of female participants either were part-time or full-time employees and many were without father cooperation; the youngest child’s father was not present in 89% of families (U. S. Congress, 1996). The policy clearly indicates that single mothers with low incomes have to work to support their families (Falk, 2013). This places first the value of mothers as economic suppliers for their families over their worth to their kids as care providers (Seccombe, 2011).

TANF is based on the conceptual stance that jobs and marriage will put an end to the need for public assistance for parents (Katz, 2012). This policy is based on the theory that if parents are married and employed, their finances will be entirely sufficient lift themselves and their families out of poverty, and they will no longer have to rely heavily on federal government assistance programs (Falk, 2013). The current welfare plan is based on the notion that the necessary first step is for parents to get a career, even if it is a low-earning or part-time job, in order to eventually gain a decent living and climb the economic ladder (Pavetti & Acs 2009). The concept was that recipients could advance to better pay positions within a 5-year time limit, enabling them to earn a satisfactory salary (Hildebrandt & Stevens, 2009). TANF is founded on the idea that most participants can get and retain work, and that stable employment can lead to financial self-sufficiency for beneficiaries (Corcoran, Danziger, Kalil, & Seefeldt, 2000).

This plan is targeted at unmarried mothers, especially minority groups and low-employment or unemployed mothers (Dave, Corman, & Reichman, 2012). The policy also exempts some previously permitted populations to receive benefits. Participants convicted of a crime related to drugs do not qualify for TANF benefits, although states may choose to amend or reject this statute (PRWORA, 1996). States also have the opportunity of punishing drug test recipients for drug use (Falk, 2013).


Discussion

Subsequently, childhood poverty dropped from 21% of all children living in poverty throughout the United States to 16% from 2000 during the first 5 years of the implementation of TANF (U.S. Government Accountability Office, 2010). The number of families with an unemployed person receiving cash aid went from 3.8 million in 1994 to less than one million in 2001, there was a rapid decrease in families receiving aid. Even though child poverty levels initially dropped after PRWORA’s enactment, the child poverty rate increased steadily in 2002, reaching its peak of 22 percent in 2010, exceeding the pre-TANF rate of 20.8 percent in 2005 (U.S. Census Bureau, 2012). The number of adults residing beneath the level of poverty has expanded from 11.4% in 1995 to 13.7% in 2012 (U.S. Census Bureau, 2012).

One of TANF’s more notable long-term effects is that it has decreased the number of discretionary cash aid qualifying households (U.S. Government Accountability Office, 2010). There were a total of 4.8 million households a month receiving cash aid in 1995, the year before PRWORA was enacted (U.S. Government Accountability Office, 2010). The figure fell dramatically in 2008 to an estimate of 1.7 million households a month receiving aid (U.S. Government Accountability Office, 2010). This was not, though, attributed to an improvement in the economic self-sufficiency of the nation, As demonstrated by a significant growth in the number of qualifying households who do not receive financial assistance. By 2005, 10 years after TANF was implemented, the number of households who were eligible for federal income support, but did not receive benefits increased dramatically to about 60 percent of all qualified families equal to 3.1 million (U.S. Government Accountability Office, 2010).

TANF follows a working-first strategy, which relies on bringing beneficiaries into the workplace by placing work requirements on recipients (Dave, Richmond, Corman, & Das, 2011). One of the unexpected consequences is that education and training are de-emphasized and higher education and job training programs are restricted for recipients (Dave, Reichmn, Corman, & Das, 2011). Higher education and training rates will result in higher paying jobs that welfare recipients need to gain self-sufficiency (Labor Statistics Bureau, 2013). Under TANF rules, in order to receive benefits, juvenile mothers are ordered to attend high school or training and if they are full-time students, they are excluded from time limits or work requirements. This program was proven to lower teenage mothers ‘ drop-out levels by 15 percent in high school (Dave et al., 2012).

In compliance with the Code of Ethics National Association of Social Workers (NASW 2008), the key objectives of the social work profession are to enhance human well-being and help meet the basic human needs of all people, with special attention to the needs and empowerment of people who are vulnerable, oppressed and living in poverty. Evaluation of TANF is critical for the social work field because it is targeted at people living in poverty, who are disadvantaged communities, and children who are a particularly vulnerable population. Social workers have moral obligations to the wider society, including fostering services, participating in, influencing social policies, and pushing for policy changes to promote better circumstances (NASW, 2008).


Conclusion

The introduction of the 1996 welfare reform legislation culminated in wide-ranging reforms to the U.S. federal money safety net system for families with children, exchanging AFDC with TANF. The key elements of that legislation contained work requirements, lifetime limits on the period of availability of benefits, and monetary penalties for failing to comply with labor or other laws. TANF seemed to work fairly well in the immediate aftermath of the welfare reform. This trend of prosperity was strengthened by the extension of wage benefits through the EITC to low-income families with children as well as the thriving labor market of the late 1990s, which in many years presented the most ideal conditions for low-skilled workers.

The Temporary Assistance for Needy Families (TANF) initiative was created to support the self-sufficiency of needy families. States obtain block grants to build and run programs that fulfill one of the TANF’s goals. The four goals of the TANF system are: (1) to provide support to needy families in order to take care of children in their own households or family homes (2) Reduce the dependency of poor parents by encouraging employment training, jobs, and marriage (3) Prevention and elimination of out-of-wedlock births (4) Encourage the development and retention of two-parent families(Ziliak, 2015). TANF can be significantly improved whilst retaining its strong emphasis on jobs (Ziliak, 2015).


References

  • Bureau of Labor Statistics. (2013).

    A profile of the working poor

    , 2011. Retrieved from www.bls.gov/cps/earning.htm#workpoor
  • Corcoran, M., Danziger, S. K., Kalil, A., & Seefeldt, K. S. (2000). How welfare reform is affecting women’s work

    . Annual Review of Sociology

    , 26, 241-269
  • Dave, D. M., Reichman, N. E., Corman, H., & Das, D. (2011). Effects of welfare reform on vocational education and training

    . Economics of Education Review

    , 30, 1399-1415
  • Deficit Reduction Act of 2005, Pub. L. No. 19-171, Stat. 4 (2006).
  • Dobelstein, A. W. (2009). The Social Security Act in Perspective. Understanding the Social Security Act, 13–42. doi: 10.1093/acprof:oso/9780195366891.003.0001
  • Falk, G. (2013) Temporary assistance for needy families (TANF): Characteristics of the cash assistance caseload. Washington, DC: Congressional Research Service Report for Congress.
  • Fusaro, V. A. (2019). Temporary Assistance for Needy Families. Encyclopedia of Social Work. doi: 10.1093/acrefore/9780199975839.013.1301
  • Hildebrandt, E., & Stevens, P. (2009). Impoverished women with children and no welfare benefits: The Urgency of researching failures of the Temporary Assistance for Needy Families program.

    American Journal of Public Health, 99

    (5), 793-801. Doi:10.2105/AJPH.2006.106211
  • Lawrence, C. K. (2013). Temporary Assistance for Needy Families. Encyclopedia of Social Work. doi: 10.1093/acrefore/9780199975839.013.393
  • National Association of Social Workers. (2008). Code of ethics of the National Association of Social Workers. Washington DC: Author.
  • Pavetti, L., & Acs, G. (2001). Moving up, moving out, or going nowhere? A study of the employment patterns of young women and the implications for welfare mothers

    . Journal of policy Analysis and Management, 20

    (4), 721-736.
  • Personal Responsibility and Work Opportunity Reconciliation Act of 1996, Pub. L. No. 104-193, 110 Stat. 2105 (1996).
  • Reed, D. F., & Karpilow, K. (2010). Understanding the child welfare system in California (2nd ed.) Berkely: Public Health Institute, California Center for Research on Women and Families.
  • Social Security Act of 1935, Pub. L. No. 74-271, Stat. 620 (1935).
  • TANF State Plan. (n.d.). Retrieved from

    http://www.dcfs.louisiana.gov/index.cfm?md=pagebuilder&tmp=home&nid=207&pnid=158&p

    d=56.
  • U.S. Census Bureau. (2011). Poverty status of people, by age, race, and Hispanic orgin: 1959 to 2012: Current Population Survey, Annual Social and Economic Supplements. Retrieved from https://www.mdch.state.mi/us/PhA/OSR/InDxMain/acsbr10-17.pdf
  • U.S. Government Accountability Office. (2013). Child welfare: States use flexible Federal funds, but struggle to meet service needs. Retrieved from:

    http://www.gao.gov/products/GAO-13-170
  • Ziliak, J. (2015). Temporary Assistance for Needy Families. doi: 10.3386/w21038

What is the difference between a group “at risk” for poor health and a group considered a “vulnerable” population

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What is the difference between a group “at risk” for poor health and a group considered a “vulnerable” population

What is the difference between a group “at risk” for poor health and a group considered a “vulnerable” population? Provide an example of a group at risk and a group considered a vulnerable population.

1. Explain why members of these groups cannot advocate for themselves or why advocating for these groups would be beneficial.

  1. What would you advocate for?
  2. What risk are you taking as a community health nurse when advocating for the aforementioned groups?

Practical Application Of Lewins Force Field Analysis Change Model Nursing Essay

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The aim of this paper is to to describe practical application of Lewin’s (1951) force field analysis change model in reducing Intensive Care Unit (ICU) patients’ length of stay (LOS) in a Tertiary Care University Hospital.

Introduction:

This paper reports on a change from 6.5 days to 4 days reduction in Intensive Care Unit (ICU) patients’ length of stay (LOS) in a Tertiary Care University Hospital. The change was embedded with systemic assessment, planning and implementing standardized strategies for all ICU long stay patients and finally evaluating the efficiency and effectiveness of ICU bed utilization with multidisciplinary team approach.

Change is inevitable for the reason that it ingrained human lives, core processes and system reforms. Day by day many changes have been observed in health care; associated with disease processes explicitly from prevention to rehabilitation, health care norms and nomenclature, infra structures modifications, policy matters, reengineering and system transformation. Different components of health care depends on one another for assembling such changes in order to produce work like from providers to payers, hospitals to suppliers, education to regulatory bodies and research to professional associations; all these are interlinked to perform function. Many of the above stated happening are planned however at times nature takes its own turn to act as a catalyst for change for example natural occurrences like tsunami, some crucial system analysis like break through reports from Institute of Medicine (IOM) on patient safety and the quality of care provided to all the health care customers. These were just simple examples of revolutions in health care taken place on an ongoing basis. Traditionally it is believed that changes are always for the betterment however at times it has been observed that this phenomenon is proven to be cynical and challenging especially when it is not made in a haphazard manner, without pursuing change management principles. Addressing the challenge of change Fetherston et.al (2009) stated that:

“Managing changing in the health care setting is always challenging, especially when it involves transforming entrenched habits grounded in professional expectations” (p.2581).

Despite change involves resources like human, material and cost and therefore whatever is proposed for change need to be evaluated for its effectiveness and efficiency, applicability, and consequences. It also depends on the team we are working with and there are times when the team building is so strong and the communication between the team is such that adopting to a new concept is very easy versus if the team members are not on same wavelength and have a lot of differences of opinions failure to reach to a simple consensus. Coch and French (1948) concluded that “rate of recovery when learning a new task is directly proportional to the amount of participation”. To improve understanding of change dynamics Armenakis and Harris (2011) recommends that “readiness for change is distinguished from resistance to change and readiness is described in terms of the organizational members’ beliefs, attitudes, and intentions”. Change agent is a very important contributor to make change happen constructively and productively. The personal and professional characteristics, interpersonal competency all these aspects are dependent to an outcome of change. Another factor involved in change process seems to be very crucial is the timeframe require for change. Is it a short term or a long run change – which is going to measure and monitor, what about the sustainability of the proposed change etc. In order to have successful change Kotter and Schlesinger (2008) recommends and put idea in practice (Appendix) and suggested that “analyze situational factors, determine the optimal speed of change, and consider methods for managing resistance” (p1, 2). According to Lippincott-Raven Publishers 1986 “Crucial to facilitating change is selecting a strategy that is likely to produce the desired change with minimal time and resistance”.

Background

In today’s health care setting, organizational change is essential for growth and development to keep up with the market competition Although health care continues to be enmeshed with ongoing challenges of cost, technologies, access to health care, human resources, quality inconsistent with an arena where error rates are too high there are multiple growing opportunities to improve client care management and service delivery components. Changes have been observed in clinical practice based on evidence based research resulting in application of new technology, diagnostics, drug regimes, treatment profile, care monitoring and finally the patient outcomes. All these are direct provision to a customer and perhaps if we look at the wider base it heavily involves all support functions available for patient care and employees of the organization. How all these are managed with patient flow and activities? Who is accountable? Change has both individual and institutional significance; and addressing its importance Watwood et al. (1997) shared that “…changes … bring opportunity for personal and institutional growth and development” (p 162). When it comes to an institutional change; it has emphasized that it should complement the philosophy, mission and vision of the organization. Therefore Heller & Arozullah (2001) identified four key factors for successful program development and achievement and those were:

“aligning the program with the strategic goals of the organization; obtaining active senior leadership commitment, including allocated resources; securing the appropriate infrastructure to facilitate integration of recommended actions into daily practice; and setting up systematic communications with all involved stakeholders” (p551)

Several challenges exists in system when it comes to a revolution however factors define by Heller & Arozullah (2001) would help in embarking change in a more structured manner.

ICU is a consolidated area of a hospital where patients with life-threatening illnesses or injuries receive round the clock specialized medical and nursing care. Intensive care is one of the hospital’s most complex and expensive medical systems. As medical care has improved, the type of patients treated in critical care units has changed from those with acute illnesses to those suffering from complications of chronic diseases. While better technology and better ways of taking care of patients has improved longevity and general health, the patients in the intensive care units of hospitals are getting sicker and globally these beds have a high demand based on the critical needs of patients and it doubles the need in an arena where these resources are very scare and inadequate This would augment medical care required, cost of care and excess use of resources when they are not required. Long stays in the intensive care unit are associated with high costs and burdens on patients and patients’ families and in turn affect society at large. Williams’s et.al (2010) states that:

“It has been estimated that between 2% and 11% of critically ill patients require a prolonged stay in ICU, accounting for 25-45% of total ICU days, and a significant proportion of resources…”(p 459)

The cost of caring for patients in ICUs in the United States has been estimated to account for 1% to 2% of the gross national product shared by (Miller et al. 2000, Seeman & David 2004) ) whereby Haugh (2003) stated that “15% to 20% of US hospital costs represents 38% of total US healthcare costs”. According to Miller et al. (2003)

“…the total number of hospitals, hospital beds, and inpatient days decreased during the years 1985 to 2000, the number of critical care beds and days in critical care increased dramatically during the same period…”

Whereby Stricker et al (20037) found that “… only 11% of patients admitted to the ICU stayed for more than 7 days, these patients used more than 50% of ICU resources”. Furthermore, in several studies (cited in Ryan et al 1997, Wong et al 1999) the mortality of patients with ICU admissions lasting 14 days or longer was estimated to be nearly 50%. Rosenberg et al. (2001) shared that “Mortality rates are higher in ICU than in any other area of the hospital due to the complexity of patients’ medical condition”. Fakhry et al (1996) found that “70% of patients with stay longer than 2 weeks reported less than 50% functional recovery”. Esserman e t al (1995) found that “32% of ICU resources were spent caring for patients who survived less than 100 days after discharge from the hospital”.

In a tertiary care university hospital where I am presently working patients were found to be stuck in the ICU and have longer stays and in the month of January 2009 it was found to be 8.4 days and subsequently in the following quarter 1 it was 6.5 days (refer appendix 1). When explored, multiple factors aroused (refer appendix 2) and therefore to address this concern a multidisciplinary team was formed. It was proposed to undertake the work of reducing patient’s length of stay in ICU and therefore it the goal was to reduce patients’ length of stay from 6.5 days to 5.5 days in the second quarter for the year 2009.

Rogers and Shoemaker (1971) framework was used to appraise the various component of the proposed change in order to identify its strengths and weaknesses. Team assessed its relative advantages to current situation and felt that it is worth spending the time and effort for the given scenario, change seems to be appropriate and compatible with existing philosophy of the clinical area, easy to be understood and applicable by all bedside staff. Moreover the project was trialable to a pilot   before going the whole way and relevant to organizational goals.

Discussion

Changes will continue as an adaptation and at times mandatory in order to survive. Lot of literature is available when it comes to the change management in health care setting. There are models available to address organizational change, system revolution, and human transformations which address many other aspects of successful implementation of reforms.

Change process follows the same course as of nursing process and problem solving approaches.

According to Christensen a & Christensen b (2007) “Lewin’s (1951) theory of transitional change is the most used form of change implementation strategies”. The change we were supposed to undertake; this theory appeared to address many aspects of it and therefore the mechanism for identifying the social system within organization for selecting, developing and implementing the strategies to serve as a solution was done by application of this model. According to course notes Lewin’s widely cited, classic model of the change process, the three changes are:

“Unfreezing, where faced with a dilemma or disconfirmation the individual becomes aware of the need to change; changing where the situation is diagnosed and new models of behaviour are explored and tested and finally, refreezing where the application of new behaviour is evaluated and adopted”. (p53)

Huber (2006) states that:

“The basic concept of the change process was outlined by Lewin… A successful change involves three elements: unfreezing, moving and refreezing”. (p810)

Fetherston et.al (2009) emphasized the importance of major change like this and endorsed that:

“Where a major change … is implemented, models such as Lewin’s (1951) model of unfreezing, changing and refreezing can be a useful guide …”

Baulcomb (2003) states that “

“This theory places emphasis on the driving and resisting forces associated with any change, and to achieve success the importance lies with ensuring that driving forces outweigh resisting forces. Driving forces tend to initiate change or keep it going whereas restraining forces act to restrain or decrease the driving forces. The intention to reach a state of equilibrium” (p277).

Unfreezing

Lewin’s change approach fall within three steps and this is the first one where the process of thawing out the system to create motivation for change. It’s like getting the team warming up to play their cards; getting everybody on the same wavelength and organizing. Huber (2006) shared that “the first stage is cognitive exposure to the change idea, diagnosis of the problem, and work to generate alternative solutions. (p811). Though it was a great challenge for the team however the process of systemic assessment and unfreeze stabilizing the team readiness was initiated for the said change. Different strategies were brain stormed in a multidisciplinary team.ICU patients’ length of stay was gathered prospectively. Potential predictors were analyzed for possible association with prolonged ICU stay. Driving and restraining forces were studied (Appendix )

Moving

Then we proceeded with the second stage of Lewin’s theory i.e., moving and changing. It involves moving a target system to a new level maintaining equilibrium; viewing the problem from a new perspective, situation is diagnosed and new models of behaviour. This stage was determine through formation of ICU long stay committee with terms of reference, notification of long stay patients stayed in ICU for more than 7days or earlier if deemed necessary to all concerned, holding meeting with primary team everyday to discuss next course of action, identification of patients difficult to wean, patient requiring early tracheotomy to maximize discharge process, initiating daily rounds by multidisciplinary team with primary team. Furthermore, introducing expected admission discharge time (EADT) to facilitate bed identification. According to Hoda (2008) “length of stay (LOS) may be influenced by the availability of appropriate high dependency units to discharge patients”. Review on daily basis the need for bed for inpatients and emergency. Admission /discharge policy was reinforced through multidisciplinary approach. Alternate accommodation in other units like CICU and CCU which has same bed accessories and uniform care provision were identified. Early tentative beds are booked in wards before rounds in order to facilitate early bed arrangement and patient transfer.

Refreezing

The final stage is refreezing. In this stage new developments are incorporated and improvements are made to stabilize the selected strategies to ensure the sustainability of the project. Daily check at unit and divisional level by bed management coordinator and ICU team. Monitoring on shift bases by charge nurses and nursing supervisors. Interventions involving palliative care, ethics consultations, and early decision about patient transfer and orders writing, family willingness and readiness and other methods to increase communication between healthcare personnel, patients, and patients’ families were helpful in decreasing length of stay in the intensive care unit. Thus, interdisciplinary communication played a vital role in improving ICU patients LOS whereby its importance is being defined by Pronovost et al (2003) and point out that “communication failures lead to increased patient harm, length of stay (LOS), and resource use…” (p71). Hence to a major extent the daily communication strategy worked out very well and the team was successful to bring about this change. ICU length of stay was 6.5 days in quarter one and it was reduce to 5.6 days in the second quarter for the year 2009 and consequently to 4.8 and 4 day in third and fourth quarter of 2009. Fetherston et.al (2009) stated that:

“When change is managed in systematic steps with adequate evaluation and communication throughout the process, it is more likely to result in successful outcomes”. (p 2582)

Evaluating the Change Project s took place and was received very positively. Following are the most important attributes I have experienced for this successful change like it was logical, efficient, and planned not haphazard

then it was based on explanation of reason for a change so that individuals understand it. After that it was very informative and staff supported change when they were involved in assessment and planning. Change agent interpersonal competency and expertise (knowledgeable) of the given task was outstanding and hence the monitoring feedback on timely basis -to ensure that all team members is on same wave length wa carried out in a very sposticated manner.

Intrapartum Ultrasonography: Prediction of Vaginal Delivery

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Summary

Intrapartum ultrasound imaging is gaining popularity with increased application due to the relative ease of utilization and direct on-site accessibility. Though initially its use was restricted to esoteric indications and routinely applied antepartum, sonography is now increasingly being used for more mundane intrapartum indications.

These may include an illustration of the precise fetal head position, assessment of fetal head engagement and estimation of the fetal weight. Advance evaluation of the complex physiology of childbirth is now possible with intrapartum ultrasonography (including Doppler flow velocimetry). It is still, though not in use for pure clinical management purposes, i.e. development of labor (or the lack of it).

Detection of advancing cervical dilatation and descent of the fetal head are two important aspect still out of the scope of intrapartum ultrasound imaging. Determination of the descent of fetal head will be the ultimate challenge of clinical applicability of intrapartum ultrasound imaging. Hopefully, imaging, ultrasound will ultimately permit us to assess these two vital clinical parameters, which have up till now proven indefinable.


Introduction

Intrapartum ultrasound has recently been explored extensively to study the progress of labor and predict the possibility of a vaginal delivery [Tutschek et al., 2011]. Further understanding of the complex physiology of childbirth is possible due to intrapartum ultrasonography. It has been shown to provide objective information on the dynamics of different stages of labor. The prognosis for operative vaginal delivery can also be assessed by intrapartum ultrasonography [Khalil., 2012].

Avoiding difficult vaginal delivery is the primary focal point of the current obstetric practice. Digital transvaginal examination, on which depends a clinician’s ability and still regarded ‘gold standard’ for obstetric practice has several limitations [Duckelmann et al., 2010].A fairly new purpose of the ultrasound is developing and the process of gathering knowledge is underway to demonstrate the new role [Akmal et al., 2004]. By merit of its safety and non-invasive nature, given appropriate circumstances, the intrapartum ultrasound examination is applicable for most (if not all) indications currently practiced in the antepartum arena.

Assessment of fetal head station with respect to the narrowest part of the maternal bony pelvis is of essential importance for vaginal delivery to take place. Recent surveys have indicated that ultrasound imaging might allow dynamic and objective quantification of the degree of fetal head descent in the birth canal [Duckelmann and Michaelis., 2010]. Various sonographic modalities have been employed in the intrapartum determination of fetal head engagement [Henrich et al., 2006]. Success in non operative vaginal birth largely depends on the fetal descent and thus it is a central element in the clinical evaluation of progress of labor. Malrotation of the fetal head is much due to the lack of descent, causing relative cephalopelvic disproportion. Clinical assessment of fetal descent is normally carried out by biased and inaccurate digital vaginal assessment regarding the maternal ischial spines [Sherer., 2012]. The presence of molding of fetal head often makes this evaluation more imprecise. In this respect fetal descent assessment by intrapartum sonographic is a promising prospect as it may potentially present a better objective evaluation in comparison with digital vaginal assessment [Sherer., 2012].

Ultrasound examination offers valuable information before the beginning of labor, such as placental localization, presence of a neck-cord or Vasa previa, fetal presentation, weight, wellbeing, depiction of prematurity and prolonged pregnancy information. The collateral applicability of ultrasound during labor has also been studied in the literature. For example, assessment before epidural catheter placement [Iliescu et al.,2012]; intrapartum maternal symphyseal separation by transverse suprapubic ultrasound examination [Sherer., 2007]; intrapartum fetal behavior and prediction of adverse perinatal outcome based on amniotic fluid amount or biophysical profile [Tongprasert., 2006]; depiction of the molding and caput succedaneum during, but also before labor [Sherer et al., 1999]; maternal and fetal intrapartum pulsed Doppler blood flow assessment [Szunyogh., 2006]; intrapartum myometrial thickness changes, ultrasound use in the third stage of labor, or the assessment of the postvoid residual volume in laboring and postpartum women with or without epidural analgesia [Iliescu et al., 2006].


Intrapartum ultrasound in labor

Several evidences suggest that clinical evaluation during labor is not always accurate with potential major implications in decision making and prognosis of delivery mode. Different studies suggested that the unorthodox configuration of the maternal pelvis and comparatively large dimensions of the fetal head at term, not all diameters of the latter can necessarily pass through all diameters of the maternal pelvis. So, vaginal delivery requires the essential adjustment or adaptation of various parts of the fetal head to different segments of the pelvis. Such alterations in place include the engagement, cardinal movements of labor, extension, descent, external rotation, internal rotation, flexion and expulsion [Cunningham, 2001]. Recent reports suggest that intrapartum ultrasound imaging may overcome these problems by application of a series of evaluations for determination of fetal head position and progression during labor thereby offering a better prediction of successful vaginal delivery.


Intrapartum sonography in assessment of fetal head position

Assessment of cervical dilatation, head position and descent of the head is important in labor monitoring. Intrapartum sonographic assessment of fetal head position has been studied since 1989 by Rayburn et al in an experiment with 86 women with labor having an arrest of more than 7 cm cervical dilatation and it was found that ultrasonographic technique improved the diagnosis of fetal head position, and was quite accurate in differentiating between posterior and anterior occipital position. The application of intrapartum ultrasonography in detection of fetal head position has been proven to be more precise than any other clinical transvaginal examination in later decades. Application of intrapartum ultrasonography determined that in most cases, persistent occip-itoposterior position resulted from an intrapartum malrotation [Gardberg et al., 1998]. Only 32% of persistent occipitoposterior positioned fetuses showed an absence of rotation from an initial occipitoposterior position recognized at the beginning of labor. Lieber-Mann et al., 2005 made a potential cohort study of 1562 women to assess alterations in fetal head position in labor. Sequential ultrasound examinations were done on enrollment, epidural administration and all through advanced labor (>8cm). It was noted that, of fetuses that were occipitoposterior in advanced labor, at delivery, only 20.7% were occipitoposterior. Alterations in fetal head position were frequent, and 36% of women had an occipitoposteriorally placed fetus on at least one ultrasound examination. Souka et al., 2003 evaluated the practicability of intrapartum transabdominal ultrasound imaging in determining fetal head position in contrast with transvaginal digitally examined in a longitudinal study of women in the first and second stages of normal or obstructed labor. These authors recognized that assessment of the fetal head position was not possible by digital assessment in 60.7% (122/201) of cases in the first stage and 30.8% (41/133) on the second stage of labor. When digital assessment was accessible, the connection with ultrasound assessment was average in the first stage of labor (κ = 0.59) and good in the second stage (κ = 0.77). Overall, fetal head position assessment by digital examination was accurate in 31.3% of cases in the first stage and 65.7% in the second stage [Souka et al., 2003]. They are in the conclusion that intrapartum ultrasound assessment is more accurate than a digital examination of the fetal head position, especially in cases of obstructed labor, which often requires medical intervention. It was also reported that intrapartum ultrasonography raises the accuracy of assessment of fetal head position in active labor [Iliescu et al., 2012]. An examination of 102 patients during active labor showed an overall rate of error (76%) in the clinical determination of fetal head position as whereas intrapartum ultrasound increases the accuracy of fetal head position determination during the second stage of labor. It was reported that the accuracy of intrapartum ultrsonography is 92% in the prediction of fetal head positions during spontaneous vaginal delivery [Iliescu et al., 2012]. Adaptation to accommodate different parts of the fetal head to various segments of the pelvis is therefore a significant requirement for vaginal delivery. Such positional changes constitute the cardinal movements of labor, and include engagement, descent, flexion, internal rotation, extension,external rotation and expulsion.


Engagement of fetal head

Various sonographic modalities using transabdominal or translabial USG have been employed in the intrapartum determination of fetal head engagement. An imaginary line representing the pelvic inlet is demarcated by directing the transverse suprapubically positioned transabdominal transducer towards the maternal sacral promontory. Engagement of the fetal head (or the lack thereof) is ascertained according to whether or not the fetal BPD is depicted below or above the pelvic inlet, respectively [Dietz., 2005]. Fetal head engagement in the maternal pelvis pertains to the biparietal diameter (BPD; the maximum transverse diameter of the fetal head) having successfully traversed the anteroposterior diameter of the pelvic inlet [Sherer., 2007].


Fetal head flexion and descent

Both flexion and descent of the fetal head contribute to successful engagement, which may occur during the last weeks of pregnancy or (as recent evidence suggests also among nulliparous patients) only after labor commences. Ultrasound imaging may be utilized with relative ease to depict flexion of the fetal head [Murphy et al., 1998]. This may be noted directly while tracking the fetal spine in a sagittal plane towards the fetal head. Of note, various degrees of deflexion or extension of the fetal head at the initiation of labor have been associated with lack of engagement. At times this may reflect various mechanical problems, such as an obstructing leiomyoma of the lower uterine segment or the occurrence of a face presentation (acute hyperextension), which may prevent successful engagement. Varying degrees of deflection of the fetal head may be noted as a result of movement of the depicted BPD from an imaginary line parallel to the pelvic inlet, to any angle up to 900, the latter representing an acutely hyperextended fetal head–face presentation [Barbera et a., 2009].


Intrapartum ultrasonography in detection of maternal symphysis

The Intrapartum ultrasound examination has been efficiently used for the assessment of the breadth of the maternal symphysis pubis upon engagement of the fetal head and once the major diameter of the fetal head was at the stage of the ischial spines [Bj ¨orklund., 1997]. It was found that on an average width of the symphysis pubis at the onset of labor was 5.8 mm.Patients with pelvic pain reported average separation of the symphysis pubis during labor to be 0.2 mm during pregnancy. From intrapartum ultrasound it could be concluded that symphyseal separation during labor is minimal regardless of parity or eventual birth weight.


Uterine contractions

An assessment of the fact that whether transvaginal sonography of the cervix before, during or after a uterine contraction in the first stage of labor is helpful in prognosis of the path of labor was held out by Saito et al [Saito et al., 2003]. They analyzed and judged the degree of cervical shortening during a contraction in comparison to the cervical length before the contraction, of 39 nulliparous and 34 parous women with uncomplicated singleton, term pregnancies in the first stage of labor. Through a uterine contraction during the normal course of labor, the cervix was shortened by approximately 50% on average. The extent of cervical shortening was notably higher in the normal latent and active phases than in the protracted active phase, prolonged latent phase and in false labor. Nulliparous and parous women showed about the same degree of shortening in the latent and active phases. This study put forward that real-time intrapartum ultrasound examination in early labor might aid in discrimination between inept and normal uterine contractions [Saito et al., 2003].


Examination of third stage labor with intrapartum ultrasound

Ultrasound imaging has enabled further understanding of the physiology of the third stage of labor [Sherer., 2007]. In 1993 Herman et al. evaluated 25 normal deliveries and five with a prolonged third stage of labor [Herman, 1993]. Normal third-stage labor could be split into four phases: the latent form, qualified by a thick, placenta-free wall and thin, placenta-site wall; the contraction stage, with a thickening of the placenta site wall (from <1cm to >2 cm); the withdrawal phase, when the placenta completes its separation and detaches; and the expulsion phase, which involve a sliding motion of the placenta [Herman., 1993]. Surprisingly, the routinely used uterotonic agents have little say in the findings. The three sonographic phases of separation were: the interval between delivery of the fetus and the beginning of placental separation (latent phase), monophasic or multiphasic shearing off of the placenta (detachment phase), and the interval between completing placental separation and vaginal delivery of the placenta (expulsion phase) [Krappet et al., 2000]. In 57 cases with clinically normal placental separation, blood flow between the placenta and myometrium ceased immediately after delivery of the fetus during the latent period. These authors concluded that cessation of blood flow between the basal placenta and myometrium following delivery of the fetus was the sonographic hallmark of normal placental separation. Persistent blood flow demonstrated by color Doppler sonography was suggestive of placenta accrete [Krappet al., 2000]. Application for intrapartum ultrasound examination in clinical management of the third stage of labor has centered mainly upon retained placenta (or fragments thereof) and confirmation of placenta accrete [Sherer, 2007].


Intrapartum ultrasound in evaluating the progression of the fetal head

A number of reports provided intrapartum sonographic data about the progression of the fetal head in an infrapubic approach, aligned in the midsagittal plane, and the contexts of the machine adjusted for widest insonation angle, maximum depth and lowest output frequency, so that the pubic symphysis and fetal skull contour could be visualized almost completely along the screen. Besides the patient in a semirecumbent position with her legs flexed may be tempted to push (push test) to dynamically determine the advance of the fetal head within the birth canal [Iliescu, 2012]. In 2009, Barbera et al presented the measurement of a new parameter of transperineal ultrasound the angle of progression as an objective, precise and consistent method for measuring the descent of the fetal head during labor, after studying 88 term laboring patients with a singleton fetus in cephalic presentation. The same technique was used by Kalache et al., in 2009 on 26 term women with prolonged second stage of labor and occipitoanterior position, which disclosed a substantial kinship between the angle of progression and the indication of cesarean section delivery. The authors establish that the calculated probability of either an easy and successful vacuum extraction or spontaneous vaginal delivery for an angle of progression of 120° was 90%. The Intapartum ultrsonographic technique is quite effective in prospective analysis of the angle of progression [Kalache et al., 2009], linear measurements and the semi-subjective assessment of head direction during the normal phase of labor [Eggebø, 2008]. Intrapartum ultrasound becomes an important examination in the assessment of fetal head position, and for the decision-making before instrumental vaginal delivery. Both supervision of the labor progress and performing the safe operative delivery can be effectively monitored with the help of ultrasound. In addition it can also be used for effective prediction of whether a vaginal delivery would be successful [Iliescu et al., 2012].


Three dimensional ultrasound

Recently, three-dimensional assessment software designed for labor measurements was developed and all the measurements noted above may be computed based on a single 3D volume scan, stored, superimposed and displayed with previous set of measurements in order to visually appreciate any significant alterations in fetal head progression and rotation during labor. The three measurements, head direction, angle of progression and progression distance, together with the angle from the center crease of the school principal to the vertical line of the pelvis have been integrated into 3D software called Sonography-based Volume Computer Aided Display, (SonoVCAD). The aim of SonoVCAD is to supply an objective measure of advance of the fetal brain during labor. Still, on that point are no prospective studies using this instrument to establish which of the measurements are more reliable and accurate in the anticipation of vaginal delivery and in general there is a restriction of these measurements to an anterior position of the fetal occiput [Zimerman., 2009].


Conclusion

Vaginal birth is a natural process, but occasionally calls for urgent medical intervention to ward off damage to the laboring woman and her unborn child. Intrapartum translabial ultrasound is a simple yet effective technique that improves the understanding of normal and abnormal labor. It makes possible to evaluate and monitor the birth progress and offers a more scientific foundation for assessing labor. Furthermore, the usage of ultrasound is of essential importance in performing a safe operative delivery and can aid in the prediction of whether a vaginal delivery would be successful.

Smoking and The Theory Of Planned Behaviour Essay

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Adolescent Tobacco Smoking through the Theory of Planned Behaviour

There is no safe level of smoking. Tobacco smoking among adolescent Australians is at an all time high. Nearly 40 000 Queensland secondary school students are classified as current smokers (Epidemiology and Health Information Branch, 1992). Research evidence indicates that if these students continue this poor life choice into their adult life, up to 10 000 of them will die from smoking related illnesses (Epidemiology and Health Information Branch, 1992). The only way to avoid detrimental health effects linked with tobacco smoking is to sidestep cigarettes as a whole. Perceived behavioural control from the theory of planned behaviour aims at the belief that one has, and can exercise, control over performing behaviour, this applies fittingly within the solution to reducing tobacco smoking among the young Australian population.

Fatalities and illnesses regarding tobacco smoking among young Australians, has become an epidemic within Australia. “In 2014/2015, one in seven (14%) Australians aged 15 years and over smoked daily” (Heart Foundation, 2019) Smoking is the largest single preventable cause of death and disease in Australia. “Smoking kills almost 18,800 Australians every year” (Heart Foundation, 2019). It is estimated that seven in ten deaths from drug-related causes (tobacco, alcohol, and drug use) are due to cigarette smoking. Young Australian smokers is equivalent to an estimated 14,503 Australian school children progressed from experimental to established smoking behaviour in 2017 (Heart Foundation, 2019). There are many factors which can lead to smoking onset, for example, weight control. However, the myth of this is that smoking does not lead to weight loss. It can slow down the metabolism and prevent weight gain, however, this can take up to a few years and should be no reason as to why smoking onset occurs. Smoking during adolescence or childhood causes respiratory and asthma-related symptoms including shortness of breath, coughing, phlegm and wheezing. Smoking impedes lung development and causes the early beginning of lung capacity decrease during late youth and early adulthood. Youngsters who smoke have an expanded danger of growing early indications of coronary illness (Cancer Council Victoria, 2016).

The Theory of Planned Behaviour (TBP) can pose successful in assuming a variety of social cues, however, it hasn’t been successful in envisaging the epidemic of smoking. Marieke Hiemstra’s article, titled, ‘Smoking-specific communication and children’s smoking onset: An extension of the theory of planned behaviour’ aimed to test whether parental smoking-specific communication and parental smoking related to smoking cognitions derived from the Theory of Planned Behaviour in association with smoking onset during preadolescence. The TPB is designed to predict and interpret human behaviour in specific situations. With respect to smoking, the TPB posits that smoking cognitions (i.e. attitudes, self-efficacy and social norms) predict the intention to start smoking. In turn, intention to start smoking predicts actual smoking onset. Assumptions regarding potential results of smoking lead to positive or negative frames of mind towards smoking, convictions about the regularising smoking beliefs of significant others lead to social standards and convictions about the presence of variables that may encourage or avoid smoking lead to refusal self-viability of smoking (Hiemstra, Otten, Van Schayck, & Engels, 2012).

Hiemstra’s aim throughout the study was to assess whether “distal smoking-specific maternal communication (i.e. frequency and quality of communication) and parental smoking is important in shaping children’s smoking cognition” (Hiemstra, et., al, 2012). The study predicted that the links present in past adolescent literature would similarly align with preadolescents also. This link to previous adolescent literature relates to the commencement of smoking as a child and smoking-explicit correspondence relates indirectly to smoking commencement through smoking cognitions (Hiemstra, et., al, 2012). In relation to parental smoking, it was predicted that this would create a link to child smoking onset directly and indirectly by smoking reasoning’s (Hiemstra, et., al, 2012). Researchers tested for contrasting effects on incidence and quality of communication between the adolescents and the mothers. Through the TPB and the behaviours connected to adolescent smoking with “smoking – specific parenting practices and corrected for data collection method (phone vs. questionnaire)” (Hiemstra, et., al, 2012). Some parents may overemphasize their parenting skills to conform to the norm of being a ‘good’ parent. Therefore, it is vital to study how children perceive their parents, parenting practices.

In sum, the current findings suggest that during preadolescence, smoking-specific communication of parents and parents’ own smoking behaviour contribute to the formation of smoking cognitions prior to smoking onset (Hiemstra, et., al, 2012). At this young age, only pro-smoking attitudes was associated with smoking onset. However, several studies have shown that also self-efficacy and social norm are associated with smoking onset later in life. Present findings suggest that cognitions that increase the likelihood of smoking onset in adolescence may already take place years before actual smoking onset. Therefore, prevention programmes, such as Smoke-free Kids aimed at families with children in primary school are important in stimulating communication about smoking.

A Dutch home-grown tobacco smoking prevention program within the Netherlands was assessed through the randomised control trial technique. Data was gathered before randomisation. This study focused on gathering families from institutions such as primary schools, media and health experts. In particular, primary school boards were to distribute letters to all children within the school aged nine to 11 years old and to then pass this letter on to their parents (Hiemstra, et., al, 2012). Participation in this study was monitored by either returning the letter to the school or a registration online via a protected webpage. In order to partake in this study, the families had to match the following criteria: all children must be between the ages of nine to 11, the adult participating needed to be a female guardian of the child or the mother, and clearly the adult and the child participating needed to be of a competent level of interpreting Dutch (Hiemstra, et., al, 2012). One child per family was entitled to partake to minimise bias and keep the study as simple as possible.  “A total of 1478 mothers and children were selected. Families were contacted by phone by trained interviewers (61.2%) or they received written questionnaires by mail (38.8%)” (Hiemstra, et., al, 2012). Radbound University in Nijmegen selected trained Master students to conduct the telephone interviews with the mother and child participants. The female guardians or mothers were interviewed first to confirm the criteria of the family. Following this, the children were interviewed days later. In order to allow privacy and freedom of speech, before the interview was conducted, the interviewers assured the adult and child could answer in any way they wanted and speak freely. By using close-ended questions, the interviewers were able to protect children who would follow the answers their parent would use as children aren’t as aware of this topic. The Questionnaires were sent out to families via postage and were to be given back in two separate envelopes, to ensure children were able to return their questionnaire without any intervention by their mother. It was evident that children who received the questionnaires had a different perspective on the questions being asked compared to the children who partook in the phone interviews.

This theory extrapolates evidence supporting the health behaviour of adolescent tobacco smoking. Through Hiemstra’s article the theory of planned behaviour was explained through smoking-specific communication and children’s smoking onset. Therefore, it overall describes the smoking-specific communication of parents and parents’ own smoking behaviour contribute to the formation of smoking cognitions prior to smoking onset. Hiemstra’s article takes a different approach to why tobacco smoking among teens is such an epidemic. It touches on the cognitive aspects of smoking, however intricately explains the science and mental battles youngsters face from this addiction.

Hiemstra’s study exhibited three strengths. Firstly, focussing on preadolescence instead of most generic studies focussing on just the adolescence phase in which children mostly begin smoking, allowed the researchers to see into the perspective of preadolescents as to reasons why smoking takes place. Secondly, by using a large sample size of 1478 children, “which allowed us to test the conceptual model derived from the TPB” (Hiemstra, et., al, 2012). Thirdly, to gain more insight into smoking -specific communication, using the mother and child data enabled the study to see this. Although few strengths, there are numerous limitations within the study that must be addressed. Firstly, Hiemstra’s study was cross – sectional study. Smoking matures through several phases, the results found within this study directs to the worrisome risk factors at various phases of smoking. A more suitable design would have been the longitudinal study as it focusses more on the development of smoking and connected risk factors in adolescents and “allow testing for potential bidirectional relationships between smoking-specific parenting and cognitions” (Hiemstra, et., al, 2012). Secondly, due to reports from children of their own smoking reasonings and smoking attitudes, which points to the red flag of recall bias or social desirability as it poses a threat to the results of this report. However, previous research on similar studies show that self – report data are quite dependable, and discretion is guaranteed. Thirdly, after assessing adolescent smoking cognitions, it is a possibility that children perceived a more negative attitude as they were conscious of what the report was testing and the existing social norms. It is directed that in order to overcome this, using the implicit measure of attitudes and comparing “implicit with explicit attitudes” (Hiemstra, et., al, 2012). Fourthly, Hiemstra’s study only targeted the perspectives of female figures and failed to recognise the attitudes of father figure behaviours. Due to this, the lack of evidence found on mother – father communication and partnering efforts from both parents is currently missing.  The self – efficacy questions asked within the questionnaires and interviews may pose too intricate for young adolescents to imagine as children are definitely too young of an age to encounter a situation where they will be forced to refuse any smoking endeavours. Therefore, in future research with pre – adolescents, Hiemstra’s researchers recommend “measuring, in addition to self-efficacy skills, also self-regulation as a precursor of self-efficacy to measure the effect of the environment on the behaviour of the child” (Hiemstra, et., al, 2012.) Finally, families were recruited from primary schools, media and health professionals. Specifically, primary school boards were asked to distribute letters to all children aged nine to 11 years old and to request that children give this letter to their parents. This automatically poses unreliable to the study. Entrusting children to deliver a letter to parents is massively untrustworthy. Simply, sending an email to all parents would have been the smarter option as it ensures direct contact with the adults and validity that the letter was received.

Overall, as an intern within Queensland Health, it can be corroborated that through the TBP, tobacco smoking among adolescence must be addressed immediately. The TPB doesn’t particularly connect with young tobacco smoking. There are numerous limitations that follow the TPB construct. Firstly, Hiemstra’s study was cross – sectional study. A more suitable design would have been the longitudinal study as smoking-specific parenting and cognitions. Secondly, recall bias or social desirability poses a threat to the results of this report. Thirdly, it is a possibility that children perceived a more negative attitude as they were conscious of what the report was testing and the existing social norms. Although a variety of limitations, there were few strengths. This study focussed on preadolescence as well as adolescence unlike most studies to encapsulate pre – pubescent attitudes. Secondly, by testing the conceptual model from the TPB allowed for the study to use a large sample size of children. Lastly, using both the parent (mother) and youngster’s perspective, allowing for smoking – specific communication. Therefore, due to all of this information it can be concluded that Hiemstra’s article was informative in providing smoking-specific communication and children’s smoking onset: An extension of the theory of planned behaviour.


References

Music Therapy for Traumatic Brain Injury (TBI) | Research

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CHAPTER – I


INTRODUCTION


“



Music gives a soul to the universe, wings to the mind,




flight to the imagination and life to everything”



– Plato

Head injury (Traumatic Brain Injury) is defined as an insult to the brain, not a degenerative or cognitive nature, but caused by an external physical force, that produces a diminished or altered level of consciousness which results in impairment in cognitive abilities or physical functioning.

(American Head Injury Founda


tion, 2012)

Traumatic Brain Injury can result when the head suddenly and violently hits an object, or when an object pierces the skull and enters brain tissue. Approximately half of severely head injured patients will need surgery to remove or repair hematomas or contusions. Some common disabilities include problems with cognition, sensory processing, communication and problems with behaviour or mental health.

(Newman, 2003)

Road Traffic Accidents (RTA) are the sixth leading cause of death in India with a greater share of hospitalizations, deaths, disabilities and socioeconomic losses in young and middle-age populations. It also place a huge burden on the health sector in terms of pre hospital, acute care and rehabilitation.

(WHO, 2012)

Almost 10 million head injuries occur annually, about 20 % of which are serious enough to cause brain damage. Among men under 35 years, accidents, usually motor vehicle collisions are the chief cause of death and > 70 % of these involve head injury. Furthermore, minor head injuries are so common that almost all physicians will be called upon to provide immediate care or to see patients who are suffering from various sequels.

(Allan H Ropper, 2011)

The advancement in medicine and technology has increased the survival rate of patients with head injury and many of them do have various disabilities. When injury is severe or even minor it lead to large number of behavioural and cognitive problems with the physical disability. Each patient represents a unique disabilities which include physical, visual, cognitive and behavioural abnormalities. Sensory Stimulation Programmes are usually started in the Neuro Intensive Care Unit and should be continued in rehabilitation. This may include tactile, olfactory, visual, gustatory and auditory.

(Ellen Barkers, 2002)

Music is a magical medium and a very powerful tool. Music can delight all the senses and inspire every fiber of being. Its multidimensional nature touches the individual’s physical and psychological levels of consciousness suggested that music exerts its effect through the entertainment of body rhythms.

(Wilson & Parsons, 2002)

Music has been used as a healing force for centuries.

Appolo

is god of music and of medicine

.


Aesculapius

was said to cure diseases of the mind by using song and music


.


Aristotle taught that music affects the soul and described music as a force that purified the emotions.

Aulus cornelius

advocated the sound of cymbals and running water for the treatment of mental disorders. Music therapy goes back to biblical times, when

David

played the harp to rid

King Saul

of a bad spirit. In the thirteenth century, Arab hospitals contained music-rooms for the benefit of the patients. Music therapy began in the aftermath of World Wars I and II. Musicians would travel to hospitals, particularly in the United Kingdom and play music for soldiers suffering from war-related emotional and physical trauma.

(Lee Mathew, 2000)


Neurologic Music Therapy

(NMT) is the therapeutic application of music to treat cognitive, sensory and motor dysfunctions that come from neurologic impairment. The treatment is based on stimulating music perception and production parts in the human brain. The targeted neurologic disorders like Stroke, Autism, Huntington’s disease, Cerebral palsy, Alzheimer’s disease and other neurological disease affecting cognition, movement and communication (mild , moderate or severe traumatic brain injury).

(Blosser & DePompei, 1994)


Need for the Study:

Everyday men, women and children suffer head injuries. A fall, a car accident, a sports injury – these everyday injuries can range in severity from concussion to coma. Traumatic Brain Injury can be fatal or, in survivors, can produce persistent problems that significantly affect the livelihood and well-being of millions around the globe. Ninety-five percent of trauma victims in India do not receive optimal care during the “golden hour” period after an injury is sustained, in which health care administration is critical.

(Indian Head Injury Foundation, 2010)

The annual global incidence rates of traumatic brain injury ranges from 91 per 100,000 populations to 546 per 100,000. The traumatic brain injury constitutes 70–90% of all head injuries, with rates of hospital treatment ranging from 100 to 300 per 100,000 populations per annum. This high variability in incidence is due to sampling of population ranging from only hospitalized patients to all the patients who visit emergency department. A large number of cases are not treated at hospitals; the actual rate is possibly in excess of 600 per 100,000 cases. There is bimodal distribution of brain injury with peaks at age group 15–24 years and after 65 years.

(Centre for Disease Control and Prevention, 2010)

The annual national incidence rates among 28 states of India, the mortality rate per million population due to road traffic accident. A varied from as low as 20 in Nagaland to as high as 216 in Tamil Nadu. States with rapid and high growth in motorization had a higher number of deaths. Nearly half of the total road fatalities were in the 4 states of India, Tamil Nadu (14.5%), Andhra Pradesh (11.4%), Maharashtra (11.1%) and Uttar Pradesh (10.2%).

(National Crime Records Bueareau, 2005)

A combination of neurological and neuropsychological deficits seems to contribute to residual handicap in patients with head injury. Neurological deficits include motor deficit (55%), ataxia (49%) and anosmia (46 %) along with memory impairment, poor initiativeness and increasing irritability. Among them very least could return to their occupation and occupational and psychological rehabilitation may found to be more effective.

(Zebenlozer and Oder, 1998)

Over the past few decades major advancements have been made in the management of patients with traumatic brain injury and significant improvements have been made in their care in the pre hospital and emergency department settings. Patients with complex, multisystem trauma are admitted to critical care unit and these patients require complex care.

(Lind D Urden, 2010


)

Rehabilitation is an important part of the recovery process for a traumatic brain injury patient. The patients with brain injury are completely dependent on health care providers to meet all their needs. Rehabilitation should begin as soon as possible after brain injury patient is stable, often with 24-48 hrs after resuscitation. The overall goal of rehabilitation after a traumatic brain injury is to improve the patient’s ability to function at home and in society.

(Davis & White, 1995)

Music therapy benefits patients across the spectrum, from premature infants in neonatal intensive care units responding to lullabies to swing band numbers in elderly Alzheimer’s patients’ moods and appetites. Involving the primary care givers take care in auditory stimulation program will helps in continuity of care and also helps to reduce cost of care.

(German, 2003)

Broca’s area is important in processing the sequencing of physical movement and in tracking musical rhythms. It is critical for converting thought into spoken words. Scientists speculate, therefore, that Broca’s area supports the appropriate timing, sequencing, and knowledge of rules that are common and essential to music, speech, and movement. The brain areas involved in music are also active in processing language, auditory perception, attention, memory, executive control, and motor control. Music efficiently accesses and activates these systems and can drive complex patterns of interaction among them.

(Michael Thaut & Gerald Mclntosh, 2010)

Complementary and alternative therapies are now the fastest growing areas of health care. Music therapy is one of the best and cheapest alternative methods. Teaching the care giver about the auditory stimulation helps to promote care and satisfaction to the patient. For many individuals, music is a source of pleasure and therefore more preferable. Hence the researcher believes that the use of auditory stimulation for patients with brain injury provides the rehabilitative as well as physical assistance with most cost effective manner.


Statement of the Problem:

A Study to Evaluate the Effectiveness of Auditory Stimulation on Motor and Verbal Responses among Patients admitted in Intensive Care Unit with Traumatic Brain Injury at Selected Hospitals, Salem.


Objectives:

  1. To assess the motor and verbal responses among patients with traumatic brain injury in experimental group and control group.
  2. To evaluate the effectiveness of auditory stimulation on motor and verbal responses among patients with traumatic brain injury in experimental group and control group.
  3. To associate motor and verbal responses among patients with traumatic brain injury with their selected demographic variables in experimental and control group.


Operational Definitions:


Effectiveness:

Improvement of motor and verbal responses among patients with traumatic brain injury after implementing auditory stimulation along with routine nursing care as observed by Glasgow Coma Scale Score.


Auditory Stimulation:

In this study it refers to auditory stimulation in which classical instrumental music therapy is given to patients with traumatic brain injury using I pod for twenty minutes for three times a day.


Motor function:

In this study it refers to patient actively moving upper extremities or lower extremities as response towards the auditory stimulation with best motor response 6 in G C S score.


Verbal response:

In this study it refers to ability of the patient to respond orally towards the auditory stimulation with maximum GCS Score of 5.


Traumatic brain injury:

It refers to injury to the brain resulting from external mechanical force such as violent blow or jolt to the head. In this study it refers to patients diagnosed to have traumatic brain injury with GCS between 8 -12.


Assumptions:

  1. Sensory stimulation may increase the motor and verbal responses among patients with traumatic brain injury.
  2. Nurses can enroll music therapy as a simple nursing intervention to promote the well being among patients with traumatic brain injury.


Hypotheses:


H



1



:

There will be a significant difference in the pre test and post test motor and verbal responses among patients with traumatic brain injury after administering auditory stimulation in experimental group at P ≤ 0.05 level.


H



2



:

There will be a significant association between pretest scores on motor and verbal responses among patients with traumatic brain injury with their selected demographic variables in experimental group and control group at P ≤ 0.05 level.


Delimitation:

  1. Study period is limited to 4 weeks.


Projected Outcome:

  1. This study would help the nurses to enlighten their knowledge regarding auditory stimulation.
  2. Nurses can utilize music therapy as an integral part of their routine care to the brain injury patients.


Conceptual Framework:

Conceptual models are made up of concepts which are words describing the mental images of phenomena and proportions which are statements about concepts. It provides a schematic representation of some relationship among phenomenon.


Ernestine Wiedenbach, (1964)

proposed a prescriptive theory for nursing which is described as conceiving of a desired situation and the ways to attain it. Prescriptive theory directs action towards an explicit goal.

The present study is based on the concept of providing auditory stimulation to patients with traumatic brain injury patients. The investigator adopted Wiedenbach’s Helping Nursing Art Theory (1964). This theory, describes the desired situation and way to be attained. It directs action towards the explicit goals. This theory has three factors

  • Central purpose
  • Prescription
  • Reality


Central Purpose:

It refers to what a nurse wants to accomplish. It is an overall goal towards which a nurse strives. The central purpose of this study is to evaluate the effectiveness of auditory stimulation on motor and verbal responses among patients with traumatic brain injury


Prescription:

It refers to the plan of action for the patient. It will specify the nature of the action that will fulfil the nurse’s central purpose. The prescription of this study is providing auditory stimulation to patients with traumatic brain injury .


Reality:

It refers to the physical, psychological, emotional and spiritual factors that come into play in situation involving the nurses. The five realities identified by Widenbach’s are agent, recipient, goal, mean activities & frame work.

According to this theory, nursing practice consist of 3-steps, which are all guiding the researcher to attain the desired objectives.

Step – I Identifying the need for help.

Step – II Ministering the needed help.

Step – III Validating that the need for help was met.


Step-I:

This involves determining the need for help. The investigator assesses motor and verbal response among patients with traumatic brain injury by Glasgow Coma Scale score and demographic variables through the structured interview schedule.


Step-II:

After identification of the patient’s needs ,the researcher facilitate the plan for care and implement it. In this study , the researcher provided auditory stimulation to the experimental group. Wiedenbach theory defines the five realities:

Agent: Nurse Investigator.

Recipient: Patients with traumatic brain injury.

Goal: To determine the effectiveness of auditory stimulation

on motor and verbal responses among patients

with traumatic brain injury.

Means and activities: Implementation of music therapy.

Frame work and facilities : Sri Gokulam Specialty Hospital and

Sri Gokulam Hospital


Step-III:

This is accomplished by means of validation of the prescription. It is done through the pretest and posttest assessment of the motor function and verbal response among patients with traumatic brain injury. If there are no significant changes in the perceived behaviour we need to reconstruct the experience to ascertain step – I & II.



























Not included in study


Figure-1.1: Conceptual Frame Work Based on Modified Wiedenbach’s Helping Art of Clinical Nursing Theory (1964) on Effectiveness of Auditory Stimulation on Motor and Verbal Responses among Patients with Traumatic Brain Injury.


Summary:

This chapter dealt with introduction, need for the study, statement of the problem, objectives, operational definitions, assumptions, delimitations, projected outcome and conceptual framework

Older People With Strokes

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An estimated 150,000 people have a stroke in the UK each year (Scottish Stroke Care Audit 2005/2006) with a mortality of over 67,000 (British Heart Foundation, 2005) . It is the third most common cause of death in England and Wales, after heart disease and cancer (NHS, 2001).This is in accordance with the report published by World Health Organization stating, “stroke is the third highest cause of morbidity and mortality in the developed countries of the world, immediately following ischemic heart disease and malignant diseases(WHO, 2008).Because strokes are common and lead to substantial disability and ill-health, a large proportion of the NHS budget is spent on treating people who have suffered a stroke. The direct cost of stroke to the NHS is estimated to be £2.8 billion. The cost to the wider economy is £1.8 billion (NHS, 2001).Thus a needs assessment of this population group might help understand the intricacies of this issue.

This assignment aims at giving a brief account of the factors influencing the health of people who have suffered stroke and further plan and justify a health needs assessment for the same. It will also attempt to provide a critical analysis of a relevant health policy and its impact on the affected population.

Stroke: Definition and Risk Factors

The World Health Organization defines stroke as “a condition caused by the interruption of the blood supply to the brain, usually because a blood vessel bursts or is blocked by a clot. This cuts off the supply of oxygen and nutrients, causing damage to the brain tissue”. The effects of a stroke depends on which part of the brain is injured and how severely it is affected. A very severe stroke can cause sudden death (WHO, 2008).

Various physiologic and medical conditions can precipitate stroke. The risk factors can be categorised into biological, environmental, socioeconomic and behavioural. There is often an interplay of two or more factors that attribute to morbidity.

Biological:

These include age, gender and genetic predisposition. The single most important factor that increases the chances of stroke threefold is the age of the individual (Fisher, 2001).

Age

People most at risk for stroke are older adults, particularly those with high blood pressure, who are sedentary, overweight, smoke, or have diabetes. Incidence rises exponentially with age and majority of them occur in persons older than 65 years (Fisher, 2001). Wolfe, Rudd & Beech (1996) states that the risk of stroke doubles with each successive decade over the age of 55. Older age is also linked with higher rates of post-stroke dementia.

Gender

In most age groups except older adults, stroke is more common in men than in women. However, it kills more women than men, regardless of ethnic groups (Fisher, 2001). This may be partly due to the fact that women tend to live longer than men, and stroke is more common among older adults. Women account for about 6 in 10 stroke deaths (NHS, 2001).

Race and Ethnicity

In as diverse a population in England and Wales, the minority population, especially those belonging to the African and South Asian origin, face a significantly higher risk for stroke and death from stroke than the English (Wolfe, 1996). They also have a higher prevalence of obesity, diabetes, and hypertension than other groups. However, studies suggest that socioeconomic factors also affect these differences.

Lifestyle Factors

Smoking: People who smoke a pack a day have almost two and a half times the risk for stroke as nonsmokers. Smoking increases both hemorrhagic and ischemic stroke risk (Wolfe, 1996). The risk for stroke may remain elevated for as long as 14 years after quitting, hence an earlier quit is recommended (NHS, 2001).

Diet: Unhealthy diet (saturated fat, high sodium) can contribute to heart disease, high blood pressure, and obesity, which are all risk factors for stroke(Winter, 2001).

Physical Inactivity: Lack of regular exercise can increase the risk of obesity, diabetes, and poor circulation, which increase the risk of stroke.

Alcohol and Drug Abuse: Alcohol abuse, including binge drinking, increases the risk of stroke. Drug abuse, particularly with cocaine or methamphetamine, is a major factor of stroke in young adults. Anabolic steroids, used for body-building and sports enhancement, also increase stroke risk.

Heart and Vascular Diseases

Heart disease and stroke are closely tied for many reasons. People who have one heart or vascular condition (high blood pressure, high cholesterol, heart disease, diabetes, peripheral artery disease) are at increased risk for developing other related conditions (British Heart Foundation, 2005).

High Blood Pressure. High blood pressure (hypertension) contributes to about 70% of all strokes. Hypertensive people have up to 10 times the normal risk of stroke, depending on the severity of the blood pressure in the presence of other risk factors. Hypertension is also an important cause of so-called silent cerebral infarcts, or blockages, in the blood vessels in the brain (mini-strokes) that may predict major stroke. Controlling blood pressure is extremely important for stroke prevention. A meta-analysis of nine prospective studies, including 420,000 individuals followed for 10 years, found that stroke risk increased by 46% for every 7.5-mm Hg increase in diastolic blood pressure (Fisher,2001).

Atrial Fibrillation. Atrial fibrillation, a major risk factor for stroke, is a heart rhythm disorder in which the atria (the upper chambers in the heart) beat very quickly and nonrhythmically (British Heart Foundation, 2005). Between 2 – 4% of patients with atrial fibrillation without any history of TIA or stroke will have an ischemic stroke over the course of the year. Of those with atrial fibrillation, the risk generally is highest in those older than age 75, with heart failure or enlarged heart, coronary artery disease, history of clots, diabetes, or heart valve abnormalities (Winter, 2001).

Diabetes

Heart disease and stroke are the leading causes of death in people with diabetes. Diabetes is second only to high blood pressure as the main risk factor for stroke. The risk is highest for adults newly diagnosed with type 2 diabetes and patients with diabetes who are younger than age 55. African-Americans with diabetes are at even higher risk for stroke at a younger age (Wolfe, 1996). Diabetes is a particularly strong risk factor for ischemic stroke, perhaps because of accompanying risk factors, such as obesity and high blood pressure.

Obesity and Metabolic Syndrome

Obesity may increase the risk for both ischemic and hemorrhagic stroke independently of other risk factors that often co-exist with excess weight, including diabetes, high blood pressure, and unhealthy cholesterol level (Winter, 2001). Weight that is centered around the abdomen (the so-called apple shape) has a particularly high association with stroke, as it does for heart disease, in comparison to weight distributed around hips (pear-shape).

Stroke being a syndromic illness, the health needs of those at risk and post stroke survivors are varied and need due consideration.

Health Needs Assessment in Stroke Survivors

Health needs assessment according to the NHS health needs assessment workbook is a systematic review of the health issues facing a population leading to agreed priorities and resource allocation that will improve health and reduce inequalities. This ensures that any action taken minimises harm to health, and may improve it for those with the most to gain. In particular, stroke is a leading cause of adult disability (Raina, 1998). The trajectory of care for stroke is of sudden onset, acute hospital care followed by rehabilitation and return to community living. Of new stroke survivors, an estimated 56% go directly home after acute care, 32% go to inpatient rehabilitation, and 11% go to long-term care facilities (NHS, 2001). Stroke survivors returning to the community often have difficulties performing every day activities like dressing, eating, and mobility that can last well into the first year post-stroke (Mayo, 2002). It is also commonly associated with cognitive changes (e.g., 26.3% of ischemic stroke survivors are diagnosed with dementia (Desmond, 2000)). Caregivers provide essential support to these individuals when they return home with varying levels of physical and cognitive difficulty.

The assessment of health needs, involves a combination of epidemiological assessment of disease prevalence, the evaluation of the effectiveness of treatment and care options, and their relative costs and effectiveness, analysis of existing activity and resource data, and application of this knowledge to populations (Bowling, 2009). Thus according to pallant (2002) it is important to identify the ‘needs’ not ‘wants’ so as to achieve measurable improvement from an intervention. As this involves time and efforts and results in considerable long term benefits for those who undertake it and for the population assessed. Hence it has attracted the interest of policy makers, health economist and health professionals to satisfy individual and population needs to optimize resource utilization (Lari & Gari, 2005). In the present context the aim of health needs assessment for stroke is to lower the incidence of stroke, directed at reducing smoking, reducing socio-economic deprivation, lowering blood pressure and encouraging healthy lifestyles (Stevens, et al., 2004)

Thus the health needs of stroke survivors during various phases of their post stroke recovery period as discovered in the literature are summarized as follows

Biological aspect

Biological pathology of post-stroke is neuromuscular function impairment which hinge on the lesion area on the brain. Undoubtedly, sensory-motor assessment such as visual field defects, bladder in dysphasia, sensory impairment and muscle power weakness (Klara, 2006). Also, motor paralysis is still a major problem in stroke condition that presents a weakness on the affected side particularly upper and lower extremities, due to lack of muscle tone generation and imbalance of nerve impulse from cerebral cortex which leads to flaccidity and spasticity (Fawcus, 2000).

Therefore in order to evaluate post stroke management and care, use of a variety of standardized tests before physical rehabilitation training can help to assess the general and specific needs of the patients. For example, the Modified Ashworth Scale (MAS) can assess muscle spasticity, the Medical Research Council Motor Power Score (MRC-MPS) can measure motor power and strength of isolated group of muscle and Likert-type scales use to count pain condition (Fasoli et al. 2004). In addition, the Barthel Index can evaluate functional skills of activity of daily living (Shah et al. 1989). These instruments and therapeutic modalities can assess the accurate physical condition and abilities of the stroke survivor and help perform strategic plan for his rehabilitation.

Physical aspects

After the stabilization of the patients medical condition the clinical emphasis is on preparing the patients to return home. The most important physical competency to be monitored in the stroke survivors by the health professionals at this stage are related to activity of daily living (ADL skills). As Gresham (1986) suggests “independence in ADL will continue to be a suitable hallmark of physical restoration”. Therefore the aspects that need consideration include education and training of stroke survivors and care givers to help them safely perform the activity of daily living and adapt the training received in the hospital to the home environment. For example, in the home environment bathrooms may be smaller, hallways may be narrower, carpets may be difficult to manage, and stairs may be difficult to negotiate. The sudden transition to the home with an absence of health professionals with whom to consult as needed may also make caregivers anxious. As a result, caregivers may need advice from peers and/or health care professionals on how to manage the care recipients’ various needs (Cameroon & Gignac, 2008). They may require additional training, and they may need additional emotional support to address fears and anxiety associated with starting to provide care in the community.

Emotional and needs

Stroke survivors need continued practice and support in their activities of daily living and would benefit from the opportunity to test their skills in the home environment under the supervision of rehabilitation professionals and/or nurses (Pallant, 2002). These professionals could appraise and provide feedback about their functioning ability with the aim of enhancing stroke survivors’ skills and confidence. Emotionally, stroke survivors need support from social workers and/or family and friends to manage their mounting anxiety and uncertainty about their skills and competence in the community(Cameroon & Gignac, 2008). The types of resources include access to community care agencies, on-going rehabilitation, and support groups.

Behavioural needs

The first and foremost priority in post stroke rehabilitation is to control the modifiable risk factors in stroke survivors. Several modifiable risk factors that contribute to development and progression of stroke include hypertension, cigarette smoking, diabetes mellitus, excessive alcohol consumption, lack of physical activity, dietary and hyper-cholesterolaemia (Gariballa, 2004). Multidisciplinary team approach not only helps in prevention but also to identify the susceptible population at risk. It is the primary health care team including clinical governance who leads the team (Pallant, 2002). Studies have shown that hypertension is the single most attributable factor for stroke. Smokers are at three fold risk of stroke when compared with non- smokers and 10 fold risks when in combination with raised systolic blood pressure (Wolfe, Rudd & Beech, 1996). Diabetes accounts for 10-20% of all strokes whereas epidemiological studies have confounded that alcohol consumption has direct dose dependent effect (Lindley,2008). Thus patients and care giver counselling in improving the lifestyle related factors and regular monitoring of the patients during post stroke rehabilitation is mandatory for long term benefits.

However in order to make the life of the post stroke survivors and the care givers more comfortable appropriate policies and their implementation should be the highest priority of the government and the Department of Health.

Policy analysis in post-stroke from National Stroke Strategy [version 2008] (Department of Health, 2008)

From the information available, the national stroke strategy tried to give data, advice and support for clear and easy implementation of treatment plan. This policy provides opportunity for stroke survivors to participate and express their health needs. Also, this persuades all institutional services of stroke to prepare pertinent information and health support into the system service to help people access information and care easily. For instance, if stroke survivors need to change service and treatment, healthcare team should explain factual information and transfer them to the right modalities by finding an accurate therapy to support them. Furthermore, if there is a voluntary organization service to serve nearby stroke patients home, health professionals should advise them to encourage joint activity in their society. Conclusively, this guiding principle explores people’s need and open people to feed back information on stroke service attribute.

The essence of involving people in developing service and treatment programme lies in the policy makers’ view to incorporate stroke survivors and carers in decision making for development of strategic plan, focus management, delivery and scrutiny of appropriate service, to provide special tools and assistive support in case of severity. The strength of this stroke policy is evident from the relevant points and emphasis on the step by step sequencing of services regarding important concerns. Besides, guideline pattern has highlighted the key words that refer to reading awareness including consistency of cartoon painting which is easy to capture in perceptual context and comprehension. However, there are a few weaknesses of informative system that cannot explain the details of further information if people need to read in-depth and cannot show the feature of voluntary organization for connection of services.

Examine how to serve life after stroke, assessment and rehabilitation

Having completed basic stroke treatment, the life after stroke needs to be evaluated with an objective for providing a good quality of life and design services for people who have had a stroke and are supported to live with independence with possible availability of resources at their home and environment. The policy aims at stroke survivors and relatives requirement of high-quality rehabilitation training and medical support in order to promote better movement/mobility in day-to- day life, self hygiene and cooking, adequate communicative skills, distress/depression management problem solving ability and sexual

behavioural understanding. The outstanding Information can help many readers and healthcare providers to realize and understand the overview of stroke patients.

All healthcare professionals should follow this guideline on rehabilitation by concentrating on individual patient needs and differing needs of some ethnic groups depending on their culture and belief in environmental society. In addition, the plan of strategy has underlined the end-of-life care by considering severe stroke survivors who seem not to get better and help them join the right service programme with the right caregiver such as special care and needs, choice of place of death and assessment of the satisfaction of patient’s relatives about the end-of-life care. Therefore, the life after stroke policy is to distinguish, to follow and depict the important roles of healthcare team but which cannot see the pitfalls of service process. If the action plan can be manipulated, according to the patient requirement from the hospital to stroke’s home and community, the end result will definitely be much better.

Analyse the process of health service in long-term care support

In order to analyse the policy service system of stroke, the stroke strategy has to be formulated to facilitate easy-to-access services and to receive concomitant service from interdisciplinary team for long-term needs of stroke survivors. Outstandingly, provision of long-term care is essential and has become a part of health promotion because post-stroke pathology is different in each patient that needs to be rehabilitated in different modality intervention programmes. Nevertheless, this policy of long-term care support is difficult to manage a range of different rehabilitations because the activity involves various dimensions and a combination of facilities for different stroke cases and hence difficult to meet the complex social care needs.

Apart from this, the stroke policy provides only an overview of immediate management and does not explain how to set the long-term care and support for stroke survivors. Although the long- term care process can lead to a better quality of life after stroke, there are many factors that need to be planned, especially related to the individual stroke condition. The guidance should be planned and made elusive in terms of mild, moderate and severe stroke in long-term care and support which is necessary for reflection of different short and long term goals to be achieved in rehabilitation training. However, the policy services merely shows people’s needs assessment and do not describe the

effective planning that meets individual needs particularly related to long term care and hence should be considered accordingly to the level of stroke condition to identify specific social care needs, including the purpose of longer-term follow-up with evaluation in multispectral collaborative services.

Discuss home modification, return to work and community participation

To improve the quality of life in post-stroke environment, the stroke policy makers provide only with a framework for adapting the home to be compatible with patient’s needs for him/her to be independent but do not give details of provisions for daily life activities. The conceptual strategy has illustrated general requirement of services for transportation and housing management by pondering over housing needs related to adaptation and modification but does not analyse specific factors that may have both positive and negative impact on the development of post-stroke skills as well as that may obstruct independence in functional ability at their homes. Nevertheless, there are no details of home modifications that are mandatory in sample such as slope area, stairway, toilet, bed room and kitchen.

Conclusion

From the above it is clear that the burden of disease due to stroke and the its impact during the recovery period deeply affects the life of the survivor. The high incidence and prevalence of disease make it necessary to implement appropriate measures to prevent first ever and recurrent strokes. Moreover a well planned rehabilitation of the stroke survivors is vital for improved prognosis. Conclusively an assessment of the health needs of this population group can be used to optimize health care services and facilities in the best interest of the survivors. This can also be used by the policymakers in improving the relevant provisions in meeting the health needs of the deprived.

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Multiple Sclerosis: Pathophysiology- Treatment and Procedures

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Multiple Sclerosis

Multiple Sclerosis (MS) is an autoimmune disorder that affects the central nervous system. This disease results in dysfunction of the voluntary muscles.  The exact etiology of MS is unknown.

Multiple Sclerosis is characterized by relapses and exacerbation periods. It usually does not adversely affect the life expectancy. However, the patient can eventually become quadriplegic as a result of this disease. MS is one of the most common causes of disability among adults in the United States. There is currently no cure for MS.


Pathophysiology

MS causes axonal injury and demyelination through an inflammatory process. As the myelin is destroyed, patches of scarring develop in the white matter of the CNS. These patches are known as ‘plaques’. MS normally affects the neurons in the spinal cord and brain (Ignatavicius, 2016).

Since the myelin are responsible for transmitting messages, the plaques can disort or delay impulse transmissions between the CNS and the body. During the initial phase of MS, remyelination can occur. However, new lesions can also develop, which eventually cause neuronal injury and atrophy. Damage becomes permanent after multiple exacerbation periods. As the extent of damage expands, the patient loses voluntary muscle function, which leads to quadriplegia (Ignatavicius, 2016).


Risk Factors

MS chiefly affects people between the ages of 20 and 40. It also affects women twice as often as men. The specific etiology of MS is unknown. In many cases, there is a family history of MS, most often in a first degree relative.

Though the cause is unknown, the disease is thought to be an autoimmune response or viral infection. Factors that trigger relapses include viruses and infectious agents, physical injuries, emotional stress, pregnancy, and overexertion. MS also occurs most commonly among whites, but can affect people of all races (Ignatavicius, 2016).


Clinical Manifestations

Since the clinical manifestations of MS are variable, it can sometimes be difficult to relate them to the disease process, and ultimately leads to a delayed diagnostic period.  The clinical symptoms may result from involvement of sensory, motor, visual, and brainstem pathways (Garg & Smith, 2015). It is important for the healthcare team to gather as much information on the patient’s noticeable changes in order to make a diagnosis as soon as possible.

One of the most common clinical findings of MS is fatigue and weakness, especially of the lower extremities. Other findings may include pain or paresthesia, vision changes, vertigo, dysphagia, and generalized muscle weakness. Bladder and bowel changes can also be a manifestation.


Complications

The biggest complication of MS is paralysis, which can progress to quadriplegia. This complication itself leads to many other complications including impaired skin integrity, and decreased activity tolerance. Decreased sensation from myelin damage can also lead to bladder and bowel issues, such as incontinence and UTIs. It is important for the patient to be mindful of these complications, so they can be proactive and stop serious issues arising from these.

Speech changes and dysphagia are both common complications of MS. This complication can lead to more serious things, such as choking or decreased nutritional intake. Speech therapy is a good resource for MS patients to aid in management of this complication (Henry, et al., 2016).

Cognitive changes are also seen in patients with MS. This complication can manifest as confusion, or even just irritability. The patient’s cognitive status should be monitored regularly. The caretakers and healthcare team should have an interventional plan to promote cognitive function. This plan should include keeping the patient in a routine, and reorienting the patient when needed (Henry, et al., 2016).


Standards of Practice


Medical Management

Since there is not an established cure for MS, medical management can be complicated. It normally revolves around caring for the patient’s specific complications. Lessening the affects of the usual complications is a focal point for care. This can be a crucial part of long term care of the patient.

It is important that the patient is aware of exacerbation triggers and knows how to avoid them. For example, exercise and stretching is important to maintain muscle function. But, overexertion and overheating can lead to relapses. Physical therapy and occupational therapy consults should be initiated for home environment assessment. These professionals can help the patient ease into changes in mobility and promote independence as the disease progresses (Henry, et al., 2016).



Pharmacological Treatment

Pharmacological treatment varies and depends on the phase of the disease. Treatment may include corticosteroids, antispasmodics, anticonvulsants, stool softeners, anticholinergics, beta-blockers, and immunosuppressive agents (Henry, et al., 2016). Some of these medications are used to target and delay the disease process, while other are used to treat the complications caused by the disease.

Corticosteroids, such as prednisone, reduce inflammation during relapses. Dantrolene, tizanidine, baclofen, and diazepam are antispasmodics which are used to treat muscle spasticity. Anticonvulsants, such as Carbamazepine, are used for paresthesia. Beta-blockers, such as Primidone and clonazepam, are used to help control tremors (Henry, et al., 2016).

A few medications are used to promote normal elimination patterns. Docusate sodium is a stool softener used for constipation. Propantheline is used for bladder dysfunction.  Regular elimination is an important part of management of MS (Henry, et al., 2016).

The most significant progress has been the development of immunomodulatory therapies (IMTs). Interferon beta is a common medication used from the immunomodulator class. These medications help alter the course of the disease, and are also used to treat acute relapse. However, they also produce nasty side effects, including flu-like symptoms, elevated liver enzymes, and depression (Garg & Smith, 2018).


Laboratory Data and Diagnostic Procedures

There is no single laboratory test or diagnostic procedure that is a definite diagnostic tool for MS. Collective results of multiple test or diagnostic tools can work together to diagnose MS. Abnormal CSF findings, including elevated protein levels and elevated white blood cell counts.

Most patients with MS have noticeable IgG bands in their CSF fluid as well (Ignatavicius, 2016).

According to Kamm, Uitdehaag, & Polman (2014), “The diagnosis of MS is based on the demonstration of MS-typical CNS lesions disseminated in space (DIS) and time (DIT) based upon clinical findings alone or a combination of clinical and MRI findings”. MRI studies will show plaques on the brain and spine. This is the most diagnostic evidence, but is used comparatively with CSF lab test.


Nutritional Considerations

Nutritional considerations for the patient with MS can change as the disease progresses. One important nutritional change should be an increase of fluid intake.  The patient should also eat a balanced diet, as described below.

The patient’s diet should be low-fat, high-fiber foods. The should also increase their intake of dietary potassium (Silverstri, 2014). The patient’s nutritional status should be assessed and monitored regularly, and modified as needed. It is important for the patient’s intake to meet the metabolic needs.


Standards of Care


Priority Nursing Actions

Priority nursing actions for the treatment of MS include monitoring the complications, and informing the patient and family about what they should be expecting as the disease progresses. Nursing actions should focus on patient safety, since that is the priority.

The nurse should monitor cognitive changes and plan interventions to promote cognitive functions (Henry, et al., 2016). Another important nursing action is to promote energy conservation. This is especially important because overexertion and exhaustion can lead to exacerbation on the disease. Maintaining safe hospital and home environment is very important to reducing the risk of injury.


Client Education

Client education is very important for these patients, since they will be going through many changes as their disease progresses. This education should focus on patient safety and injury prevention. The client and family member will need to be educated on medications, safety considerations, and nutritional changes.

Instruct the client to avoid fatigue and stress as much as possible. This can be done by balancing moderate activity with rest periods. The client should be instructed about nutritional changes and considerations, as described above. The client and family should also be instructed about sensory changes that will take place. The client should use a thermometer to check the temperature of bath water, and should avoid heating pads. Using assistive devices can help with motor loss (Silvestri, 2014).

Another important education topic is safe self-administration of prescribed medications, especially self injections. It is important for the injection sites to be rotated periodically. When presenting the client this information, it would be helpful for them to have a support person with them to help recall the information later. Supplemental pamphlets for the patient to have at home can be very helpful with the educational aspects.


References

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    . doi:10.1002/brb3.362
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    . Eur Neurol 2014;72:132-141. doi: 10.1159/000360528
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